Lack of Cooperation Disorder

Let’s talk frankly. Are you really very interested in reducing your emotional distress? Do you really want to feel better? What if feeling better requires that you change your daily habits, change your habits of mind, change your circumstances, upgrade your personality, and work like the Dickens? I mean, seriously—are you up for that?

You say that you don’t want pills—well, do you want all this responsibility instead?

You say that you don’t want to talk endlessly in therapy—well, do you want all this responsibility instead?

You say that you don’t want to live like this any longer—well, do you truly want to live differently?

See if this is you. You are suffering and you seek out a helping professional whom you hire to help you relieve your emotional distress. Unfortunately for both of you, you have certain powerful reasons for not cooperating with this person you have hired.

Maybe you don’t want your drinking, smoking, or eating habits tampered with. Maybe you don’t want to change—you want other people to change. Maybe you can’t reveal what’s going on because you’re embarrassed by your thoughts or your actions. Maybe there would be repercussions—say, if your mate found out about your affairs. Maybe you’re very comfortable with your formed personality and your habits of mind, even though they bathe you in sadness or anxiety.

This would make you entirely human and not very unusual. In fact, virtually all people prefer being who they are to being helped or reducing their emotional distress—if being helped and reducing their distress makes work for them, requires that they change, or forces them to look in the mirror.

It is an artifact of evolution that our “selfish genes” are not very smart. They cause us to defend ourselves even against self-help. It might prove in your best interests to make certain admissions and take responsibility for healing and for changing, but most human natures rebel against such brutal honesty.

This reality surely doesn’t much help the helping relationship.

These are “your issues”—but they also become the issues of the helping professionals you hire. You are forcing them to deal with human nature and they get very tired of human nature. The whole current thrust of mental health services provision in the direction of “diagnosing and treating mental disorders” and “medicating patients” is rooted in exactly this failed transaction.

What modern psychiatrist isn’t happier acting like you “have something” and writing you a prescription than trying to arm-wrestle you out of your personality, your habits of mind, and your ways of being? Wouldn’t you be rather likely to do the same in his position? And aren’t you just a little glad that he is telling you that you “have something”? Doesn’t it serve your ends to “have depression,” rather than look at your sadness, or “have an attention deficit disorder,” rather than manage your anxiety and pay attention?

Aren’t the two of you in this together?

Maybe you are more unwilling to cooperate, say because you have secrets to keep, or maybe you are more unable to cooperate, say because your chronic sadness has you so down that you have no energy to use in your own support. These are different situations but from a helper’s point of view they amount to a similar problem: you aren’t helping. And that has consequences for you, because your lack of cooperation must get factored into the diagnostic label you get and, in turn, into your prognosis and your treatment plan.

How could it not?

And what if you are not only uncooperative but also up front and adamant about it? Say, for example, that you make a point of being uncooperative and make a further point of doubting your helper’s expertise, methods, and even his good intentions? Isn’t that going to count against you? Of course it must!

Picture a psychiatrist, a psychologist, or a psychotherapist of some other stripe. If you disagree with him, if you mock his expertise, if you see him as an agent of society and not as an actual helper, he will almost certainly provide you with a harsher diagnosis than if you are pleasant and act cooperative. Isn’t that just natural?

If you are uncooperative and loud about it, you are less likely to get some adjustment disorder diagnosis or some mood disorder diagnosis and more likely to get a personality disorder diagnosis. Just as a judge has a remedy for “difficult and unpleasant” in his arena—contempt of court—a therapist-as-judge has his particular remedy. He has the ability to diagnose you with a “borderline personality disorder” or an “oppositional defiant personality disorder” or something else that translates as, “Boy, are you difficult!”

This is all covert, of course. A psychiatrist would never say, “Because you are being uncooperative I am giving you a harsher label.” He might say, “Your lack of cooperation is a symptom of your personality disorder”—that he might just say. But that is a very different sort of sentence.

He might provide you with this harsher diagnosis for two different reasons: because he is annoyed with you but also because once he gives you that precise label he is relatively off the hook as far as treating you goes, since it is “well known” that folks with personality disorders are by-and-large unreachable and untreatable.

You get the label because you are a pain in the neck but you also get it because it reduces his responsibility dramatically, since “nobody can reach someone with a borderline personality.” You, by virtue of being difficult (and you are), and he, by way of preferring an easier ride, collude in providing you with a label that completely obscures the failed nature of the transaction.

A person’s general unwillingness to participate in reducing his own emotional distress because it is too much work to do so, coupled with a therapist’s wish to take it easy on himself when dealing with uncooperative clients, leads us to this exact moment in the history of mental health helping, with drugs running rampant and everyone acting as if human beings have caught this or that version of some craziness flu.

The scandal that is the DSM-V is a professional scandal. But it is also the completely predictable result of two agendas colliding: the collision of the client’s wish to remain the same and the helper’s wish to make it through the day.

We in critical psychiatry who are looking at alternatives to the DSM and to our current diagnosing madness must somehow factor this reality in. How good can any new system be if it doesn’t take into account that human beings are only mildly interested in reducing their emotional distress? In medicine, the issue is compliance: will a patient take his meds or stop eating fried foods? Our issue is an even more intractable version of the same problem.

Maybe every new client should start out with a “lack of cooperation disorder” diagnosis—maybe with refinements like “mild,” “moderate,” or “severe”—until he proves that he is actually interested in cooperating. No—we certainly do not need another disorder label! What we need is a new education system that alerts children from the beginning of life that if they want a certain outcome like emotional health they will need to work for it.

It is actually easy enough to imagine what that education might look like—if only anyone wanted it.

Eric Maisel is the author of 40+ books. His latest are Secrets of a Creativity Coach, Why Smart People Hurt, and Making Your Creative Mark. His latest offerings are Life Purpose Boot Camp classes and instructor trainings. To learn more about Dr. Maisel’s books, services, workshops, and classes please visit http://www.ericmaisel.com. You can contact Dr. Maisel at ericmaisel@hotmail.com.

7 Comments Already

Kudos to Dr. Maisel. I think you’re truly onto something. You are asking of readers here at DxSummit, many of the questions that I was asked when doing my own therapy, 40 years ago. I think this process is ultimately constructive. Some of these questions eventually challenged me to do my life differently. And perhaps they inspired the therapist with whom I worked for two-plus years, to leave the profession for a more honest line of work.

Dr Maisel, may I build upon your themes?

For some people reading your article, it might seem that you are blaming patients for their difficulties and resistance to change. Or doctors for their hidebound refusal to recognize that they sometimes (often?) react to difficult patients with harsh labels, rather than continuing to bore in on change or greater personal empowerment as the real agenda. I don’t see such issues in your discourse, but some probably will. Change is tough, but self-justification remarkably easy.

But then, a question for you: what paths lead out of this blame-game circle? How do professionals know when to discharge patients with the admonition, “come back when you’re serious about change”, instead of prescribing a pill? How does the larger society recognize and correct practitioners whose methods and medications need to be challenged for the damage they do to patients?

Likewise, let’s apply the principles that you ably illuminate, to our own readership. Might we apply the label “professionalized oppositional disorder” to the seeming unwillingness of discussants to even consider (much less enact) concrete steps which actually change something of import to their own practices? Or are self-congratulatory discussion and debate the only real objects of the exercise here?

I offered a framework months ago, for discussing concrete steps toward change. Professionals response to “Lead, Follow, or Get Out of the Way” has been a crashing silence. Might I then infer that many of the learned participants here are suffering from a kind of emotional denial of their own? Indeed, the same resistance displayed by many of the difficult patients you describe? And of course compounded by their feeling that I AM one of the difficult patients you describe?

Dr Maisel, your article brings a new urgency and insight to the age old admonition, “Physician, heal thyself!” It may also illustrate a familiar principle that I believe very much needs to be taken to heart by professionals: if you aren’t part of the solutions, then you become part of the problem. Doctors, how much are you a part of the problem? And what are you going to do about it? WHEN?

I’m not sure if my first comment made it through, so I will leave another one. This essay seems like a great example of putting responsibility where it doesn’t belong. Putting responsibility on those suffering emotionally (the ‘clients’ of the field of mental health) for the field’s inaccurate and unethical practices (the medical model). Putting responsibility on children to raise themselves as emotionally healthy instead of on the people who are supposed to raise them and ensure their well-being and healthy growth. Blaming lack of progress or therapy success on clients’ simply ‘not wanting to change’ rather than on any problems with the ‘therapy’ model and/or the therapist’s education.

You know what? Most people who have been suffering most of their lives (generally due to parenting problems – again, please read “The Manual: The Definitive Book on Parenting and The Causal Theory,” or any other book by Faye Snyder, PsyD) do not need to be further poked, prodded, invalidated, and talked down to. They really just don’t need that from the MH profession, as they receive more than enough of it from the general culture as well as, often, from their own families (which is where the problems generally start). The very fact that the parenting they received was problematic already set them up at a disadvantage from their earliest years. I really do encourage you to read Dr. Snyder’s work and perhaps you will come away with more understanding, empathy, and knowledge about the genesis of ‘personality disorders’ and their associated emotional distress, and maybe you will give suffering and striving people more benefit of the doubt. Seeing as how the education of therapists and MH professionals is apparently so confused and lacking at the present time, I feel it is very inappropriate to make their clients the ones responsible for the field’s failures. It seems akin to a parent blaming their child for what are their own (parenting) failures. Please don’t tell me that that’s something you condone as well.

I enjoyed this…it has lots of truth in it…but it’s far too easy on the professionals who do, indeed, explicitly coerce and force treatment in ways that are pretty heinous and not at all interested in the well-being of the person who is being “treated”. And when that is happening cooperation is simply not healthy and being uncooperative is truly a life affirming sign of inherent well-being in the client.

I most certainly was interested in changing my life and personality. I was interested in truly and deeply growing and I still got slammed up full of drugs (by a pretty nice doctor who didn’t have any other tricks up his sleeve) even while seeking alternative care that didn’t exist at the time. I sought other answers until taking on the gargantuan task of freeing myself from drugs on my own with the help of other patients since MDs didn’t know how to safely help. This remains a tragic and dangerous problem.

So yeah, I got gravely harmed by a nice doctor with whom I cooperated while always seeking alternative and more holistic care because I was committed to growing and changing…and I hated the drugs. They are soul killing neurotoxins.

And I’m not alone…I have 1000s of readers who are taking on self-healing protocols because no one gave them those options when they were being treated by the mental illness system.

there are lots of people who want to do the heavy lifting you are referencing here but they don’t know where to go for that sort of help, because, frankly, as this article also suggests, the mental health professionals haven’t done their own heavy lifting…so they don’t know how to help their clients…and some of us have enough of a sense of discernment to recognize that…

so, while I enjoyed this article it’s truly only about a sliver of what is going on…there is a much more broad and nuanced reality…

I too worked as a social worker in mental health for 15 years…I’ve seen this from both sides of the proverbial couch.

In AA they say you can’t help an alcoholic until he or she hits bottom. i.e. not only has the person gotten past the denial but is recognizing the need to change. AA is mainly self-help, with a group and a mentor as a support system.

You explore denial. There’s denial in the individual and denial in society. Today we live in an era in which the doctors’ message is, “just take this pill; it will make you well; just be medically compliant.” It encourages passivity–we get it from TV all the time.

Fortunately I’m old enough to have had pediatricians who trained before World War II (before antibiotics). Back then the doctor-patient relationship depended much less on medications and more on the doctor having extensive prior experience with a disease and of acting as an emotional support, helping the patient to rally their will to live and get well, which in turn strengthened their immune system. It involved a long-term relationship, included knowing his patient’s strengths and weaknesses (and of when and how to prod or comfort); doctors visited sick people in their homes; also, many women were skilled in home nursing. That tradition of doctor-patient-family relationships was passed down informally through the medical generations and has suffered a significant loss in the last 60 years.

Today’s situation reminds me of living in a disfunctional family. Some problems that arose in generations past were kept secret; the younger generation learned the rules without knowing why or what happened. Or the problem is in the transition to the modern world which has discarded good ways of coping that worked for many generations and has not recognized the unintended consequences of the losses that occurred in the process of change.

I’m glad that, although you started by blaming the patient(s) you acknowledged this is a two-way street. That the need for change is at least as much in the mental health system as in its patients.
Where did the problems all start? Blaming the other is a trap that’s hard to get out of; it’s a way of avoiding the pain and the challenge of reforming a whole system.
The mental health system has had its own “borderline” or “oppositional defiant personalities” like Thomas Szasz, D L Rosenhan, Sandor Ferenzci and scores of others who saw the problems and the need for reform generations ago.

As an educational scientist it is my understanding that a teacher has become more of a didactic administrator rather than a pedagogue. This shift in practice also means alot to the teacher – student relationship. As the teachers focus will center around administrative tasks and didactic planning, the pedagogical understanding of the students has to be set aside to a great extent making the communication between the teacher and students even harder. And then, when this student with strange means of communication, deviant behavior or just in need of some attention, make a request on top on this (in his own manner), it may be the straw that break the camel’s back and the request for medication of that student, or the label of the lack of cooperation disorder, may be a reality immediate. But neither medication, nor a need of a label which state the teacher experience, is necessarily needed. Pedagogical theory and practice has many possible solutions, and such the question may as well be of policy. Is there a possibility to change the policy of the education such that the pedagogical practice get a greater focus? Or is there an alternative to employ experts in pedagogy to support the teachers in the school? And what effects would such change of policies have?

The same questions of policy do I ask of the mental health system. I do not know it more than from the perspective of a patient with certainly may fullfill the criteria of lack of cooperation disorder. But it is my personal experience, from my studies into psychopathology and education, that a change in litterature has taken place: from a more stimulating philosophical focus on the diversity of mental nature toward a contemporary focus on efficient practice, similar to the understood progression of education. In other words do I wonder to which extent the system make it possible to be constructive stimulated by the diversity of problems? And how this possible factor affect the communication, and problem solving, between the therapist and the patient?

Chris, I admit that I don’t fully understand the point you are trying to make. But if I am reading you correctly, I have profound reservations with the idea that highly delusional or hallucinating people can be “taught” to attain persistently high function in society without resort to some type of medication on at least a temporary basis. None of the medications is an unalloyed blessing, and many are dangerous. But the more radical alternatives seem to amount to embracing madness as a mere inconvenience of communications rather than the distressing and often violent experience that it is in real life. That, I am not personally prepared to do.

I would also suggest that Dr. Maisel may have been using the term “Lack of Cooperation Disorder” in an ironic or satirical sense, and as an admonishment to practitioners. There is, of course, no such psychiatric entity. The points which he makes are by no means ironic or satirical, however. The dynamic between physician and patient can be a stormy and frustrating one. And patients may not be the only ones who bring toxic thoughts, reactions, or beliefs into the therapy theater.

Many therapists may need to own and outgrow their own preconceptions and even much of their training. Much of contemporary psychiatry and psychology is just flat out wrong in principle, dangerous in practice, and abusive of patients. Concrete ways to work our way out of this morass are not going to come about easily. Physicians must first remove the beams from their own eyes, before reaching to extract the slivers from their patients’.

I wish scientists didn’t feel they had to use professional jargon and would speak English (or whatever the lingua franca is).

Eric Maisel started by pointing out that making changes in our lives can be painful. That even when we’re in pain already, doing what needs to be done to heal can itself be painful. And that changing old, ingrained habits, no matter how dysfunctional, can be difficult and deeply distressing.
But then he goes on to say that this is true also for professionals in the mental health system–that to change the existing dysfunctional system that mental health is trapped in can also be very painful. And that if you’re in a position of greater power it’s much easier to blame the patient than to confront a whole system that’s pressuring professionals to just go along rather than rock the boat and say something’s wrong. And since jobs and reputations are on the rack they avoid confrontations. And it’s harder for MH professionals who presumably are certifiably sane to say “I may be sane but the system is crazy.”

Let’s compare the unequal power in the doctor-patient/counselee relationship to that of parent and child. If the parents aren’t accurately perceiving the situation and responding appropriately sometimes kids will act up–lack of cooperation–to get their parent’s attention. It’s not that there’s essentially something wrong with the kid (or even the parent) there’s something wrong with the communication–or with societal expectations.

For the DxSummit to find the answers of how to reform the system it would be good to look at some historical examples.
1. Galileo waited until he was in his last years to speak up. He knew the bind the Church was in if they admitted a mistake (see his letter to the Grand Duchess Christina). He recanted outwardly. But he’d already said what needed to be said (and does anyone know how long it took the Vatican to get interested in astronomy? They were already doing the Gregorian calender). The lesson is–trust history!
2. John Bowlby–studied psychoanalysis. Knew that kids were responding to the reality outside them more than to “fantasies.” World War II provided a most extraordinary example of how small children respond to the loss of a parent/primary attachment figure. Granted he was an interdisciplinary genius who defined attachment to a large degree on his own (with Mary Ainsworth, Harry Harlow, Konrad Lorenz, et al)and had the personality that allowed him to withstand the concerted ostracism of his colleagues. The lesson is–if you’ve got the right answer reality will support you.
3. Progress with developmental trauma–Over 20 years of work. They have far more evidence of the physiological alterations caused by trauma, interpersonal and other, than for any other diagnosis in the DSM Why then did the ApA refuse to admit DTD into the DSM-5? A great mystery! This has not stopped progress. (Unfortunately for those of us who are adults they are focusing all their resources on children).